sti-clinical

Community Health 1
Running Head: COMMUNITY HEALTH CLINICAL PROJECT
Community Health Clinical Project, Ft. Lewis, WA
Bethany Carlson, Zele Desta, Maxi Gould, Emily Haydu, Kate Huff, Kailee Pederson, LaNora
Siggelkow, Laura Vetter, and Amy Whitney
Pacific Lutheran University
Community Health 2
Introduction
During the fall of 2009, our community health clinical group had the opportunity to
experience and work with the Army Public Health Nurses at Classic Madigan. During the
semester we learned about the Fort Lewis community and the resources that the Army Public
Health Nurses provide and oversee. We had the experience of being on one of the largest army
forts as well as seeing and being a part of public health nursing. We learned that public health
nursing collaborates with the community to identify and prevent many different health issues and
concerns. Each of us had the opportunity to see different aspects in community health at Fort
Lewis such as environmental health, occupational health, child youth and school services, the TB
clinic, flu shot clinics and the special adult clinic. Our goal during this semester was to assess
and identify a community health problem and to work with the community in improving this
concern. With the help of the APHN we were able to accomplish our goal and implement
interventions to help improve this community problem.
Assessment
History
When the U.S. Army decided to place a new post in Washington State, the Army‘s
original interest was to build the post in the Spokane Valley. Tacoma businessmen attempted to
encourage the U.S. Army to establish a military post in the American Lake or Tacoma area. The
Tacoma News and Tribune publisher, Frank S. Baker, was a leader in the idea of having an
Army post near Tacoma. No one person is given credit for the idea but it took multiple leaders
to accomplish the location for the post. ―There is no finer Army post site anywhere in the United
States. In this area there is every physical condition desirable for Army training and
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maneuvers,‖ exclaimed Major General Arthur Murray during a 1912 visit to the Nisqually
Valley.
In 1916, the Major General J. Franklin Bell of the Western Department of the U.S. army
sent out personnel to inspect possible sites for a new post in the Pacific Northwest. Captain
Richard Park was sent and did not have the Nisqually Plain on his original agenda, but it soon
appeared through a Tacoma businessman‘s committee asking the Captain to visit the area. Upon
his visit to the area, he found it not only acceptable but was impressed and stated ―…the most
magnificent field I have ever seen for military maneuvers.‖ The Army was not the first to find
this location favorable for training. In 1915, Washington state troopers used what is now the
Fort Lewis area for training.
In August of 1916, Major General Bell met with the Tacoma businessmen group to
discuss how to attain the land. Later that year the Tacoma businessmen representing the Pierce
County Citizens went to Washington D.C. and spoke with the Secretary of War Newton D.
Baker, offering to donate the 140 square miles for the military base. On November 15, 1919, the
land no longer belonged to Pierce County or Washington State, but it was officially Federal
property of the United States of America. It was named Lewis after Captain Meriwether Lewis
of the Lewis and Clark expedition. Today some of the originally donated land is home to the
parade field and Gray Army Airfield.
Construction began quickly on July 5, 1917, with the first building being built within
three days. In the 90 days following the start of construction, Camp Lewis saw 1,757 buildings
and 422 other structures built and all were fully lit, plumbed, and heated. The main gate was
built upon the completion of the buildings. The original main gate still stands today, as a ruin of
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what it once was, near today‘s main Fort Lewis gate. In December of 1917, with approximately
37,000 men, Camp Lewis quickly became the largest military post in the United States.
During the construction period, the Army trained and distributed soldiers to fight in
World War I. The 91st Infantry Division trained and shipped out to France in June of 1918.
After that, the army trained the 13th Infantry Division in trench warfare, and before deployment,
the Armistice was signed on November 11, 1918. This ended World War I.
With the end to World War I, Camp Lewis experienced dramatic change. Once being
one of the most active military camps, post WWI, Camp Lewis came to a standstill. The Camp
Lewis Commander Major General Henry Greened was reassigned, and the Camp was left to
Brigadier General James A. Irons. From 1919-1927, the camp began to crumble before the eyes
of the soldiers living there. The make shift barracks started to fall apart, other buildings fell to
decay. This lack of upkeep disgusted the greater Tacoma area whose citizens had donated the
land to the U. S. government. They demanded the U.S. War Department give the land back; this
was supported by local businessmen, and newspapers. The agreement between the county and
government stated the post will remain in government hands as long as it is used for the
purposes—one in particular, a training area.
In 1925, rumors spread saying Camp Lewis was being closed and was back to civilian
ownership. During this year, some civic groups began to reclaim thousands of acres of land by
tearing down and selling building parts for scraps. All of a sudden, very suspiciously, a fire
struck. No one was ever caught in the starting of the fire, nor did anyone or any group claim
responsibility.
In March of 1926, the Secretary of War, Dwight F. Davis, asked Congress to approve a
building plan to rebuild and upkeep three army posts over the next ten years. Camp Lewis was
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one of the three selected. On September 30, 1927, the Army re-designated Camp Lewis a Fort,
as it is called today- Fort Lewis.
Through the years, the population on Fort Lewis decreased to 5,000 by 1939. But in-
between March 1939 and March 1941, the population grew to 37,000. In order to accommodate
the huge influx, Fort Lewis built a complex on what is now North Fort Lewis, a 2,000 acre area.
The new complex was completed in August of 1941. All of the growth at Fort Lewis is directly
related to the activity leading up to the American involvement in World War II.
When word of the bombing at Pearl Harbor reached Fort Lewis, it shook the community.
Quickly, after word of the bombing, Fort Lewis soldiers secured Camp Murray, McChord Field,
and Fort Lewis. During this time of war, Fort Lewis was the training home to many Infantry
divisions. A camp for Enemy Prisoners of War (EPW) was established during July of 1943; the
camp remained in operation for three years.
Also, in 1943, Fort Lewis grew by land, adding some 18,000 acres from the Nisqually
River. At the end of World War II, the 2nd Infantry Division was stationed at Fort Lewis; this
division was the first to deploy to fight in the Korean War. At the end of World War II, the
Fourth Infantry Division also was stationed at Fort Lewis. The 4th Infantry Division was
deployed to fight in the Vietnam War in 1966. Fort Lewis again became the main training post
and began sending soldiers across the Pacific, as well as in processing them when returning back
to the states. In just over six years, Fort Lewis processed over 2.5 million troops and trained
over 300,000 men.
Over the course of nearly 100 years, Fort Lewis has become what we know it today.
Currently, Fort Lewis continues to grow and is currently home to approximately 35,000 soldiers.
Demographics
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Fort Lewis has a total population of 19,089 as reported in the 2000 census compared to
that of Pierce County, which has a total of 774,144. Fort Lewis is 62.7 percent male and 37.3
female. Pierce County is 49.7 percent male and 50.3 percent female. The median age for Fort
Lewis is 22.4 years and for Pierce County the average is 35.6 years. On Fort Lewis, the highest
percent of the population is between 25 and 34 years of age, which is 27.1 percent. Fort Lewis is
60 percent White, 20 percent African American, 1.3 percent American Indian and Alaska Native
and 3.4 percent Asian. The rest of Fort Lewis is reported as people with more than one race. In
Pierce County it is reported that 77.6 percent White, 6.7 percent African American and 1.3
percent American Indian and Alaska Native. It is interesting that Fort Lewis does follow Pierce
Country trends considering so many people come and go from the base.
The average household size for Pierce County is 2.57 with an average family size of 3.1.
Fort Lewis has an average household size of 3.75 and the average family size of 3.78. About 57
percent of people in Pierce County over 15 have never been married. Fort Lewis only has about
38 percent of people over 15 as never married. This is a finding that would be expected to be
lower compared to Pierce County rates because of the benefits that come along with the military
life. In Pierce County of the population that is 25 years and older, 30.2 percent have their high
school degree. 10 percent have associate degrees, 15 percent have bachelor‘s degrees and 8
percent have graduate or professional degree. Fort Lewis has 22.2 percent with their high school
diploma of those 25 years and older. Only about 24 percent of people have their bachelors or
associate degree. Only about 5 percent have their graduate or professional degree. It is interesting
that the rates are so low because of all the educational opportunities that the Army gives to their
troops. The mean household income for Pierce County is almost 58,000 where as Fort Lewis is
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32,000. Only 1.9 percent of people on Fort Lewis are unemployed compared to 6.3 percent in
Pierce County.
Total STD rates for Pierce County were 576.3 per 100,000 in 2005. For Washington State
the rate was 600 per 100, 000. These rates do not include HIV/AIDS. In 2005, Chlamydia had
the highest incidence rate of 453.5 per 100,000 and for Washington state it was 297.6 per
100,000, which was also the highest for the state. In Pierce County, the average age of infection
of Chlamydia is 15 to 25. For the year of 2006, the rate of Chlamydia for the United States was
344.3 per 100,000. In Washington State it was 278.6, while the rate was highest in Pierce County
at 391.9. In Fort Lewis alone for the year of 2006, there were 474 cases of Chlamydia (a rate of
about 13.5 per 1,000 people). The rate and the number of Chlamydia cases nearly doubled by
2008, with a total of 1066 cases (a rate of about 30.5 per 1,000 people). See Appendix A for
graphs and tables with rates of Chlamydia and other STI's for the U.S., Washington, Pierce
County, and Fort Lewis.
Systems Theory
The systems theory is an interdisciplinary theory and framework used to show how
systems of nature, society, and science work together to produce results and explain productivity.
A systems theory is also continuous in its inputs, throughputs, and outputs which is why it can
be compared to a cycle. A systems theory can be applied to a community as well. Inputs such as
resources go into the community, resources are modified by the community in some way
(throughput), then these original resources are changed and produce an output. This activity is
cyclical in nature- as it outputs it has a need for more and new inputs, thus causing a
continuation. The Fort Lewis community as a system is comparable to a closed system in that it
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is very self-contained. However, it can also be open since it interacts with outside forces and
relies on external factors for the importation of food.
Systems theory is a basic, logical approach to understanding a complex system. It is also
a good way to show how the community of Fort Lewis functions. Within the community of Fort
Lewis, the priorities inputs of soldiers are physically and mentally trained and tested to carry out
Army missions and objectives. This training and educating by the Army to the soldiers is the
throughput of the systems theory. The output of the Fort Lewis community in this example is
trained soldiers which will go on to accomplish military tasks and goals. In the cyclical structure
of the systems theory, the output of soldiers will lead to a need for an input of soldiers. The
trained soldiers functioning as the output will then go on to train new soldiers thus continuing the
feedback nature of the systems theory and the community of Fort Lewis.
The Fort Lewis community also functions in a sustainable sense in its health care and
health maintenance system. Fort Lewis has a hospital, clinics, and community programs. These
services are inputs into the greater Fort Lewis systems theory. The throughput of these services
includes the application of health care, ―the prevention, treatment, and management of illness
and the preservation of mental and physical well-being through services offered by the medical
and allied health professions‖ through the act of caring for the health of individuals, families, and
communities. The outcome in this scenario is healthy soldiers, families, and the overall Fort
Lewis community. Fort Lewis has many resources that address the community holistically such
as services for mental health (counseling), spiritual outlets, and many physical health centers.
Many fitness and recreational services are available to increase health promotion and prevention
of disease. The need for this continuous cycle of health care at Fort Lewis is significant due to
the nature and propensity of human beings to encounter physical and mental problems. This
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cycle is then constant as the throughput attempts to care for, cure, and maintain the people of the
Fort Lewis community.
Fort Lewis offers continuous community knowledge and learning services through its
libraries and Army Continuing education services. The Army offers abundant tuition and
scholarship support in education for its members. As the Fort Lewis community individuals input
into the systems theory, education and knowledge offered by Fort Lewis functions as the
throughput. Education and knowledge act to enhance the individual and hopefully produce a
more intelligent, capable, and effective community as the output of the system.
Money, as a resource inputting into the Fort Lewis system, enables the development and
maintenance of new and old structures at Fort Lewis. Roads and transportation are also
maintained. The output of these inputs and throughputs include facilities the community can use
to carry out their activities.
Key Informants
As part of our assessment process, we interviewed key informants from the Fort Lewis
community. We interviewed several interdisciplinary workers involved in the health care system
at Classic Madigan. Our key informants consisted of an Army Public Health Nurse, the Chief of
Preventive Medicine, a Physician‘s Assistant, and a religious leader in the Fort Lewis
community. It was important to get a variety of perspectives on sexually transmitted infections
in the Fort Lewis area. As we were doing our research, we discovered that Madigan Army
Medical Center invests a considerable amount of resources to the prevention and management of
STIs. Furthermore, they are involved in collaborating information with the Tacoma Pierce
County Health Department and Centers for Disease Control (MAMC memorandum 40-28).
Mr. Johnson
Community Health 10
During the interview process, getting cooperation and attention from our key informants
was not an issue. They were incredibly helpful and willing to assist us in our project. Prior to
the interview process, we had established a working relationship with our key informants which
made the interview process seamless. Mr. Johnson is the primary care provider at the special
adult clinic (SAC). He sees the prevalence of STIs at Fort Lewis first hand in his office during
his physical examinations and teachings. He stated the problem with teens and the need for
education. “High Schools need to reinforce some moral issues—having sex could be dangerous
and a risk to health.” He also mentioned the importance of parental obligation in encouraging
safe behavior, such as abstinence. He recommended a number of possible solutions to the
prevalence of Chlamydia, Herpes and Genital Warts at Fort Lewis. When asking him what he
would like to see changed at Fort Lewis, he mentioned increasing awareness of his clinic by
posting flyers and handouts at Waller Hall and the barracks. (See appendix)
Captain Hill
When interviewing the Army Public Health Nurse, (Captain Hill), she suggested a few
solutions to the problem at Fort Lewis. Largely, she talked about the lack of education at the
SAC clinic. She pointed out the importance of adding a Bachelor level nurse in the SAC clinic.
As a Public Health Nurse, her role is limited in working with STI patients because there is no
position currently available for a registered nurse in the SAC clinic. “We need to implement an
RN in the SAC clinic to provide the education and holistic care that patients need.” When we
told her about our plan to post flyers throughout the army base to raise awareness, she thought it
was a great idea. However, she added a valid point regarding our flyer. She stressed the
importance of reassuring the service members that their confidentiality will be respected. She
stated “I recommend that you mention on the flyer that the chain of command will not be
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involved whatever the outcomes are and that information is on a need to know basis”. Captain
Hill also suggests another excellent proposal to increasing compliance and behavior
modification. “I think that the idea to put condoms and flyers/pamphlets in the examination
room is a great idea”. By implementing this small measure, it will minimize
barriers/stereotypes a patient may experience in the waiting room when taking a pamphlet from
the ‗STI educational wall‘ or taking a condom from the ‗candy jar‘ placed next to the secretary‘s
desk. (see appendix)
LTC Baker
The Chief of Preventive Medicine, LTC Baker, has been working in community health
for a number of years. She showed us the amount of educational material printed for members of
Fort Lewis. In fact, there was a walk in closet full of flyers, posters, and pamphlets on STI
prevention, awareness, and treatment options. There was information on at least ten different
types of STIs, ranging from Bacterial Vaginosis to Genital Warts. As we were looking through
the massive pile of pamphlets, we discovered that there were no flyers promoting the SAC clinic.
Our group decided to do a walkthrough of the barracks and Waller Hall, which is the in and out
processing center on post. We were looking to see if there were any signs posted concerning STI
awareness, or the SAC clinic. We did not find a single flyer raising awareness of STIs, or the
SAC clinic during our walk through. We brought this fact to LTC Bakers attention and proposed
that we do something about this by posting informative flyers around the barracks and Waller
Hall. She thought it was a good idea because of the benefits it has by increasing the awareness
of the SAC clinic. However, she added a few suggestions. “I think the quality of care offered at
the SAC clinic can be improved if the staffing is increased. Additionally, the hours of operation
can be increased to give soldiers more options”. She brought up a great point, because the hours
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of the SAC clinic are only from 0730-1030 M-F. This can be a barrier to access of care due to
the limited options it gives service members and their family members. (See appendix)
After carefully analyzing the interview data, STIs are attributed to many possible reasons.
There are several theories to this problem in our society. We spoke to a religious leader in the
Fort Lewis community, and he mentioned an interesting comment about the prevalence of STIs.
We also researched some important facts from Planned Parenthood, which supports our key
informant‘s comments. He stated that, “Our generation is drifting from abstinence. Respecting
the union between husband and wife is a driving factor from a Christian’s perspective. We are
living in a sexual society where it is taken lightly; this can be a contributing factor to our
problem”. This religious leader had an interesting point which can be applied to the STI
prevalence in Fort Lewis. This should be considered when assessing the contributing factors to
STIs at Fort Lewis. In addition, Planned Parenthood encourages abstinence as a form of birth
control and STI prevention. ―Used continuously, abstinence is 100 percent effective in
preventing pregnancy. It also prevents STIs” (www.planned parenthood.org). The fact is that
people practice abstinence for many reasons. Some may practice it for personal, moral, or
religious beliefs and others want to prevent pregnancies and STIs. After looking at abstinence
from a religious aspect along with Planned Parenthood, there are many benefits to practicing safe
sex. Regardless of the reasoning or motives, abstinence can be a safe and effective choice for the
Fort Lewis community to practice. (See appendix)
Windshield Survey
General Impressions
Fort Lewis is a multi-dimensional community; a community sewn together through years
of structure, determination, support and tradition. Fort Lewis is located in the beautiful, green
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Pacific Northwest. There are many gates in which to access this military community. The main
Liberty gate lies off of I-5, exit 120. This is where all civilian and visiting members of Fort
Lewis must come first. In order to get into the community, you have to have a badge or a pass
that is given by the Liberty main gate welcome center. There are 10 gates total that gain access to
Fort Lewis. When you do get onto to Fort Lewis, the community can appear overwhelming at
first glance, especially to someone unfamiliar with the area. First impressions of Fort Lewis
might include: structured, green, well protected, and uniform (add others from group members).
As you begin to look deeper into Fort Lewis, the friendlier community based lifestyle comes to
life.
Space/Boundaries/Barriers
Though we did not travel all 691 miles of roads, it was evident that Fort Lewis is very
diverse in how the vast space is utilized. There are wide-open areas for training, and a large
airfield with hangers. Businesses are centrally clustered together, and buildings used for various
purposes are scattered throughout. There are neighborhoods full of homes that vary in style and
age. Ft. Lewis consists of many large areas of woodlands, parks, and prairies. Though
landscaping may not be aesthetically pleasing throughout all areas of the base, Mt. Rainier‘s
picturesque beauty lies to the east and is a breath taking sight on crystal clear days.
Structures
Fort Lewis offers their enlisted members and their families a wide variety of housing
opportunities. Neighborhoods consisted of duplexes and single-family homes. The fronts of the
homes were well kept and the name of the enlisted solider is posted outside. There are parks
with playgrounds and community centers located near the neighborhoods. Officer‘s homes
differed in size and style. Some housing is much newer and appeared in better shape than the
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older homes. There are barracks available for soldiers and apartment housing is also available
for shorter stays.
Recreational facilities for soldiers and their families are located all around Fort Lewis.
There are activities for individuals of all ages to participate in. Physical fitness is an important
aspect of military life and there is a large fitness center on base. Individuals and families can go
bowling, see a movie at the theatre, or check books out of the library. Individuals can attend
other community activities such as arts and crafts or Latin sensation dancing at the Madigan
Café.
Within the gated boundaries of Fort Lewis, the community has many businesses available
to meet their needs. Clustered around the main fort for easy access, there is a PX for one stop
shopping and a mini mall. Some of the businesses are Popeye‘s, Burger King, Credit Unions,
24-hour shoppette, laundry and dry cleaning, equipment and rental shop. There are also many
automotive services including a car rental service, auto parts store, vehicle repair garage, and
four gas stations. The Fort Lewis Commissary is a large super store that offers a large grocery,
meat and produce department.
Social Services/Helping Systems
Fort Lewis offers its community members a wide range of religious services and
education. The following religious services are held at many chapels located throughout Ft.
Lewis: Catholic, Jewish, Liturgical Protestant, Protestant, Contemporary Protestant, and Gospel.
Religious education and bible studies are also offered for community members to utilize.
Fort Lewis provides Child Youth and School services to members of the army community. This
service provides soldiers opportunities to meet army requirements as well raising their family in
a healthy structured environment. These programs are designed to encompass all aspects of a
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child‘s development, including physical, intellectual and emotional. Child development services
are also provided and include day care for families.
At Classic Madigan, Fort Lewis has a cluster of public health offices that offer a variety
of amenities available for soldiers and their families. The goal of army public health nursing is
to enhance health outcomes of the individual and the community.
There are many other resources available to help Fort Lewis‘s soldiers and their families.
Madigan Army Medical Center is a large hospital that provides care to all of Fort Lewis‘ soldiers
and their families. The hospital‘s Medical Mall offers many outpatient services including
Pediatric oncology/hematology, OBGYN, pediatric clinic and more. The Soldier and Family
Assistance Center is a place to get a multitude of services that are unique to the needs of
individual soldiers and their families. There are also many clinics and programs offered for
soldiers to enhance their wellness and readiness.
Economics
The majority of work in Fort Lewis comes from the active duty military personnel. Soldiers go to
work every day to train and prepare for the skills needed to protect our country. Fort Lewis
provides many job opportunities for families of soldiers and civilians. Some opportunities
include store businesses, construction projects, fast food chains, health care employment at
Madigan army hospital and landscaping work. The ACAP also provides job fairs and
opportunities for civilians to become employed. The Civilian Personnel Advisory Center is a
center which has a web resource that is set up for civilians on Fort Lewis to help aid in job
opportunities.
Transportation/Safety
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Safety is a major concern on Fort Lewis and is evident by the 100% identification checks
at the gates prior to entering the post. Fort Lewis has a Hazard Awareness and Emergency
Preparedness Program to prepare for all kinds of emergencies. There is also strict enforcement
of ―no talking on the cell phone while driving‖; hands free devices must be used. The military
police patrol the area to help ensure safety of its community.
All vehicles must be registered at the Visitor‘s center or at Waller Hall. There are a wide
variety of vehicles driving around on post, including army vehicles, civilian vehicles, personal
vehicles, and school buses. There is a lot of traffic in the morning, around lunchtime, and in the
late afternoon. Parking is scarce, especially around Madigan Army Medical Center. People are
seen running and riding bikes. Though there were many areas lacking sidewalks, the sidewalks
we observed were well maintained.
Healthy People 2010
One of the goals of Healthy People 2010 is to reduce the incidence of STIs. Specifically,
according to focus area 25, their goal is to ―promote responsible sexual behaviors, strengthen
community capacity, and increase access to quality services to prevent sexually transmitted
diseases (STDs) and their complications‖ (HP2010). STDs are not only a burden to their carriers,
but have significant consequences for reproductive health and fetal wellbeing and are also linked
to several cancers. They are costly and cause many complications, yet they are preventable! The
main strategy to fight the spread of these infections is primary prevention, mainly through
education of the public. HP2010 points out that this significant health problem remains ―largely
unrecognized by the public, policymakers, and public health and health care professionals‖
(HP2010). STDs need to be brought into focus in order for any change to occur.
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As part of their effort toward achieving this goal, HP2010 has identified several factors
in the spread of STIs. There are biological factors to take into account, including the
asymptomatic nature of STIs, the lag time between infection and complications, and gender and
age (HP2010). STIs result from unprotected sex and because their carrier may not realize they
are infected, protection may not be used. Many infections have no signs or symptoms or have
very mild signs and symptoms, causing people to disregard them. As a result, people do not seek
medical treatment at times when they really should (HP2010). Along the same lines,
asymptomatic STIs can have a long time period between infection and complications. Due to the
fact that it may take up to years for a complication to arise, (such as cervical cancer caused by
HPV) ―people frequently do not perceive a connection between the original sexually acquired
infection and the resulting health problem‖ (HP2010). If more people were made aware of the
connection between significant health complications and STIs, perhaps they would be more
vigilant about protecting themselves.
Several social and behavioral factors also contribute to the spread of STIs, including
poverty and marginalization, substance abuse, and access to health care. STIs are more common
in areas of poverty and high-risk sexual behavior such as sex workers, adolescents, and migrant
workers (HP2010). These people often do not have access to health care to get treatment or
education about prevention. The need for publicly supported STI services is greatly needed in
these areas. Access to care is ―essential for early detection, treatment, and behavior-change
counseling for STDs‖ (HP2010). Secrecy is also an important factor contributing to the spread
of STIs. Sexuality is a very private part of someone‘s life and is not openly discussed in the U.S.
According to the Institute of Medicine (IOM), this secrecy about sex ―impedes sexuality
education programs for adolescents, open discussion between parents and their children and
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between sex partners…, education and counseling activities of health care professionals , and
community activism regarding STDs‖ (HP2010). All of these factors reiterate the point that
education and available treatment are essential to the population.
In order to develop an effective ―national system of STD prevention‖ in the United
States, HP2010 acknowledges that sexual behaviors and norms need to change (HP2010).
Openness of sexual topics needs to become the norm to ensure that sexual relationships are
consensual and honest. Openness of this matter would allow parents to talk frankly to their
children, as well as teachers and counselors to students, about responsible behavior and avoiding
sexual risks. Health care providers would also be able to form a comfortable environment with
their young clients to educate about sex and risk avoidance and to regularly screen them for
STDs as needed (HP2010).
HP2010 came up with three STD transmission dynamics: the rate at which uninfected
individuals have sex with infected individuals, the probability that an exposed person will
become infected, and the time period during which an infected person remains infectious and
able to spread disease (HP2010). These factors interact and affect the rate of STD infection. To
prevent this, interventions aimed at altering the ―natural course of these factors‖ need to be
implemented through education in schools and in the community (HP2010).
Under this overarching goal, Healthy People 2010 goes into specific objectives about
STDs they are working to prevent. Objective 25.1 is to ―reduce the proportion of adolescents and
young adults with Chlamydia trachomatis infections‖ (HP2010). Specifically, they want to
reduce the percentage of females age 15-24 years old (who attend STD clinics) who are infected
from 12.2% (1997) to 3.0% (by 2010), and reduce the percentage of males from the same age
category and diagnosis from 15.7% (1997) to 3.0% (by 2010) (HP2010).
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Reducing Gonorrhea is also an aim as stated under objective 25.2 (HP201o). The
baseline in 1997 was 123 new cases of gonorrhea per 100,000 and the target for 2010 is 19 new
cases per 100,000 (HP2010). These sub-goals are being worked toward by making the changes
mentioned earlier and implementing educational programs in communities.
Effective communication is the key to educating the public about STD concerns. For this
reason, focus area 11 of Healthy People 2010, Health Communication, is important to consider.
Their goal is to ―use communication strategically to improve health‖ (HP2010 11, 2000). Using
effective communication aids in disease prevention and health promotion by making others
aware of health risks, available treatments, resources, and support systems. Health
communication is particularly important in the community where it ―can be used to influence the
public agenda, advocate for policies and programs, promote positive changes in the
socioeconomic and physical environments, improve the delivery of public health and health care
services, and encourage social norms that benefit health and quality of life‖ (HP2010 11, 2000).
In order to successfully combat STDs, communication and resources to reach the public need to
be utilized.
Army Regulations
Army regulation 40-5 discusses preventative medicine and the establishment of
preventative services and programs. It also discusses the responsibility of improving and
sustaining health throughout the army (1-1). 1-7a2 refers to DA Pam 40-11, chapter 2 for further
information about disease prevention and control programs and services.
Chapter 2, section 2-8 of the DA Pamphlet goes into detail about the prevention and control of
STIs. According to this section, ―successful prevention and control of sexually transmitted
diseases (STDs) requires the following: (DA Pa 40-11 p 5)
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1. Accurate diagnosis and appropriate treatment of infected persons and their sexual
partners.
2. Personal interviews and epidemiological contact investigation.
3. Active surveillance at the installation level.
4. Health education directed at all sectors of the military community.
5. Reporting of STDs through the RMES as soon as possible after diagnosis.‖
Effective control and prevention of STDs also requires ―appropriate therapy and follow-up,
disease intervention, identification of locations where a high level of STD transmission may
occur and community and unit health education‖ (2-8c). A community health nurse plays an
important role in the education and follow-up of civilians and soldiers at Fort Lewis. They can
play a part in STD case interviews, counseling, treatment, and contact investigations.
In terms of what these programs should include, section 2-8e says that ―Army STD control
programs will adhere to guidance published by the CDC on screening procedures, treatment,
follow-up and prevention strategies.‖ Guidance provided by TSG on the recommended treatment
for uncomplicated gonorrhea and other STDs takes precedence over CDC guidelines.
Assessment of MAMC, Classic Madigan.
―Classic‖ or ―old‖ Madigan is the original Fort Lewis Army Hospital. It was originally
founded by Colonel Patrick S. Madigan, who was known as "The Father of Army
Neuropsychiatry.‖ When Colonel Madigan passed away in 1944, the hospital was named in his
honor. It consists of multiple single story buildings. The buildings are structured with brick and
white panel siding, with grey roofing. The buildings are very large and spread out with long
hallways. Old Madigan is currently undergoing remodeling and has many trailers set up on the
property that serve as temporary housing for many army services. It is surrounded by green trees
Community Health 21
and some housing for soldiers and families. Old Madigan houses many services that are in clinic
settings. Some of these services include: Army Blood Bank, Family Assistance for Maintaining
Excellence (FAME), military and family life consultant program, army community services
(ACS), confidential alcohol treatment and education program (CATEP), and behavioral health
services. Fort Lewis did a great job preserving a historical building and utilizing it to serve
soldiers and their families all in one convenient location.
Assessment of Preventative Medicine and Army Public Health Nursing
Preventative medicine is a series of care measures taken to prevent or inhibit disease. It
focuses on stopping the spread rather than looking for a cure. Fort Lewis has their very own
department of preventative medicine. It works to protect its soldiers and their families in order to
keep them healthy and active. The mission statement for their preventative medicine department
is, ―We are committed to serving our community by promoting public health and workplace
safety and will respond to the needs expressed by our community.‖ The goal is to educate
soldiers and their families and to have everyone become an expert on health prevention.
Becoming an expert will not only benefit families, it will also benefit the community as a whole.
This can stop disease before it starts and stop the spread of disease which leads to a decrease in
medical cost. Families will not be spending thousands of dollars on disease tests and treatments
if the disease process never occurs. Funding can be spent on continuous prevention. The Army
Public Health Nursing Department (APHN) falls under preventative medicine. They offer many
services to meet the mission and vision of preventative medicine. There are about six nurses who
run the APHN clinic. These nurses oversee and work with the occupational health, STD or SAC
clinic, and environmental health clinic. Within the APHN clinic they focus on tobacco cessation,
Community Health 22
TB, and child services. However, these nurses also participate in environmental inspections
related to the child and youth services centers.
The tobacco cessation program is a voluntary ―stop smoking‖ program. It is set up to
educate and support soldiers and family members in making the choice to stop smoking and
improve their health. Out of the six nurses there is one head nurse who oversees the program but
all the nurses trade off working for the program. Staff members are non-judgmental and
individualize care for different clients. The program provides resources and medical support in
order to stop smoking. Our group found this program to be quite successful and many referrals
were made. The head nurse of this program was great with patients and was very knowledgeable
about the subject.
The PPPT is a program that works with pregnant and postpartum women to support them
to continue physical training. It is a mortified PT program to help keep the women in shape so
when they come back from giving birth they do not have as much work to be able to meet their
tests. They stay in the program for three months after giving birth to be able to gain their
strength and wellness before going back to regular PT. They gain education and skills that will
help them stay healthy through their pregnancy. Captain Hill gave our group an excellent
briefing on the program and what it entails.
The TB clinic is located within the APHN office and also has one nurse as the lead with
the rest participating in care. The clinic involves testing, consults for positive test, referrals and
follow-ups with patients who have had a positive TB test or treatment. Our group found that the
nurses are very supportive and spend a large amount of time with their patients and do a huge
amount of education. It seemed that the patients left feeling relieved and really knew what they
Community Health 23
need to do to be well. The nurses are very much advocates for the patients and would try to get
them what they needed.
CYSS is the child and youth school services on Fort Lewis. This program involves many
different facilities that provide after school care and daytime care so soldiers can do their duties
and meet the needs of their units. The nurses for this program inspect the facilities and make sure
that things are running properly. They will also do the training for these facilities and in our
group we were able to teach some of these classes on asthmas, emergency medications, SIDS
and communicable diseases. The nurses also will evaluate children to see if they will be
acceptable to be at the after school facilities. If the children have too many medical issues, they
cannot attend the after school programs. Once again, the nurses really work hard and do a great
job at ensuring their clients are taken care of.
The occupational and environmental health clinics work outside the office of the APHN
but still falls under their department. The occupational health clinic works with all the civilian
workers for Fort Lewis. The workers come there to get medical work ups to make sure they are
fit to be hired and if they have an on-the-job injury they will come to get care. The nurses are
also in charge of around two hundred people who they have to insure they get their yearly
physicals and tests. The environmental health clinic inspects all the food facilities on base to
insure sanitation and proper food preparation. The dining facilities will be graded by the
inspectors and available for people to look up. Another priority is to test for West Nile virus in
mosquitoes. Medical waste supervision is also under the environmental health department. They
insure that waste is being disposed of properly. The workers in environmental health love their
jobs and work very hard. One inspector told us he loved coming to work and was never bored.
Community Health 24
They really save Fort Lewis and the army a lot of money by preventing illness, but as stated by
the Colonel of the department, it is hard to put a number on how much they save.
Assessment of Special Adult Clinic (SAC clinic)
Multiple members of our group spent two to three hours observing, participating, and
evaluating the clinic. We observed the interview process, treatment process, and doctor
consultations. We saw a variety of clients and STIs, with Chlamydia, gonorrhea and genital
warts being the most prevalent in the Fort Lewis community. We found the staff to be well
informed and educated on STIs. The staff was also very sensitive and non-judgmental to all
clients in the clinic. Some staff were not as thorough as others in the interview process, but
needed information was obtained. We found that it was the men speaking with male clients who
were more direct and to the point, compared with the women who talked longer and with more
detail. The temporary facility can be considered restrictive to patient care due to size. There
were adequate resources/condoms in the lobby, but our assessment found no resources/condoms
readily available for patients in the rooms or other private areas. We feel that more clients would
be willing to utilize such resources if they were in a more private area. The interview tool was
well designed with the exception of an STI education assessment. The clinic is placed in a
private location and is well disguised (yet not well marked). This is probably to protect the
client‘s privacy.
Our assessment of the surrounding area of Fort Lewis found a lack of SAC clinic
information. Upon assessing the barracks for informational flyers, we found none. The same
lack of flyers creating awareness was found in the PX, commissary, and Waller Hall. We also
noticed there was no information about the SAC clinic in the Fort Lewis Welcome Packet, which
is received by soldiers & families upon coming to Fort Lewis. There is also no specific flyer
Community Health 25
representing the SAC clinic. Because there is such a high prevalence of STD‘s in this community
the SAC clinic is a good resource for soldiers and families to utilize, which is why we feel the
SAC clinic should be advertised more.
Analysis
After gathering all of our assessment information, we came up with two nursing
diagnosis that relate to the identified community problem. The nursing diagnoses are as follows:
 Risk of sexually transmitted infections among members of the Fort Lewis community
related to the high incidence of STI‘s, risky behaviors, lack of preventative education,
STI knowledge deficit, lack of awareness of SAC clinic, and missed opportunity for
behavior modification at the SAC clinic per key informant.
(Diagnoses support healthy people 2010)
Limitations
Planning
Core Functions
The core function used in our project is assurance. ―Assurance refers to the role of public
health in ensuring that essential community-orientated health services are available, which may
include providing essential personal health services for those who would otherwise not receive
them‖ (Stanhope 2008). As public health representatives, we identified the problem of STD
prevalence in the Fort Lewis community and provided educational resources to implement
throughout the community. These resources include: an educational poster to be put up in the
barracks and in Waller Hall, adding an educational piece into the SAC clinic interview screening
tool, making resources available in patient rooms within the SAC clinic, and placing a SAC
clinic informational flyer into the orientation packet. By providing these resources to the
Community Health 26
community, we are assuring that critical preventative health information is being provided for
members of the community to help decrease rates and prevent STDs.
Short Term Goals
 Increase awareness of STD prevalence
 Increase education on STI prevention
 To increase the number of Fort Lewis community members utilizing the SAC clinic for
education, screenings, and early treatment.
Objectives for short term goals
 Soldiers and their families will receive an informational flyer about SAC clinic services
in their welcome packet upon coming to Fort Lewis by January 2010.
 SAC clinic awareness posters will be placed in the barracks, Waller hall, PX, and
commissary by January 2010.
Long Term Goals
 Increase knowledge and access to quality services to promote responsible sexual behavior
and prevent sexually transmitted infections.
 To decrease the prevalence of STIs within the Fort Lewis community
Objectives to meet long term goal
 SAC clinic will provide educational resources within patient rooms and restrooms within
a year.
 Integrate and utilize a ―current knowledge STI education assessment‖ to the SAC clinic
interview screening by December 2010.
Implementation
Community Health 27
To implement the plan we have devised strategies or ―interventions‖ to meet our goals.
Our interventions each address a level of prevention. These levels are primary, secondary and
tertiary. A primary intervention is ―prevention of the initial occurrence of disease or injury‖ (ATI
pg 7). A secondary level of prevention is the ―early detection of disease and treatment with the
goal of limiting severity and adverse effects‖ (ATI pg. 7). A tertiary level of prevention is the
―maximization of recovery after an injury or illness‖ (ATI pg 7). As public health representatives
the following interventions focus largely on increasing the use of the SAC clinic and the
resources utilized there.
Interventions for short term goal
 Assess for current information promoting the SAC clinic within the barracks, Waller
Hall, and Fort Lewis welcome packets- Primary prevention
 Place SAC and STD awareness posters in Waller Hall- Primary prevention
 Place informational flyer about the SAC clinic in the orientation packet- primary
prevention
 Placing an educational STD poster in the barracks- primary prevention
 Placing SAC clinic flyers in the PX and commissary- primary prevention
 Increase hours of operation of the SAC clinic from 0730 to 1830- secondary prevention
 Student presentation of proposed interventions to Army Public Health Nursing- tertiary
prevention
Interventions for long term objectives:
 Assess SAC clinic for adequacy and use of educational tools for prevention of STIs –
primary prevention
Community Health 28
 Gather resources to place in patient rooms and bathrooms within the SAC clinic-primary
and secondary prevention
 Put in place condoms and resources into the patient rooms and patient bathrooms within
the SAC clinic- primary and secondary prevention
 Create the ―current knowledge STI education assessment‖ to add into the interview
screening tool at the SAC clinic- primary prevention
 Suggest a public health registered nurse and a nurse practitioner be hired to improve
holistic teaching at the clinic- primary prevention
 Student presentation of proposed interventions to Army Public Health Nursing- tertiary
prevention
Evaluation
Evaluation consists of two parts; formative and summative. Formative evaluation is a
continuous evaluation process that is conducted throughout the entire project. It is a prospective
look at the progress being made. It allows for evaluation at multiple points throughout the project
to detect deficits and gaps within the knowledge base to be changed or improved upon.
Summative evaluation is retrospective analysis of how the entire project turned out which is
conducted at the end of the project. If the project has no dedicated ending point, time periods can
be developed in large intervals in which to evaluate progress.
Our project, we hope, will be continuous; therefore formative evaluations will be done
frequently. For completion of our portion of the project, we will do one summative evaluation of
the reaction and acceptance of the proposed project to the Army Public Health Department. For
formative evaluation, staff will interview clients on how they heard about the SAC clinic. Also,
Community Health 29
for one month the SAC clinic will survey clients on the effectiveness and helpfulness of the
resources provided in the patient rooms, how readily available the SAC clinic is to clients, and if
adequate education was given. For summative evaluation, the army public health nurses will
compare and contrast STI rates from year to year to assess if changes have occurred from the
interventions implemented. Further evaluations of the utilization of the SAC clinic with the goal
that clientele will increase from year to year. The Army Public Health Department will reassess
findings that were initially found. For example, a deficit in knowledge in the clientele about the
location of the SAC clinic will be evaluated for improvement.
Discussion
Closing
During the entire semester, our group had a great experience at Fort Lewis. We not only
had the opportunity to observe and participate in activities with the Army Public Health Nurses
but had the experience to help to inform about a change in education and awareness involving
the Special Adult Clinic (SAC).
References
Community Health 30
http://www.mamc.amedd.army.mil/Clinical/standards/std_main.htm
http://www.mamc.amedd.army.mil/Clinical/standards/std_main.htm
http://www.plannedparenthood.org/health-topics/birth-control/abstinence-4215.htm
Appendix
Interview
Captain Hill- Army Public Health Nurse
1. Do you think that STI’s are a problem at Fort Lewis?
Yes, it is big enough to cause a public health concern. There is an STD problem in our
nation; there is a problem in state of Washington, Pierce County, and Fort Lewis. Fort Lewis
has a big population we have about 35,000 soldiers on this post. It is our responsibility to
educate the public.
2. What STI’s are most commonly seen here?
Chlamydia runs ramped in Fort Lewis and this can be preventable. I think the education
should start at the middle school level. I think the public health nurse should be the one to go
around and educate the adolescents on post. More responsibility needs to be put on the
parents to educate their children. Currently, our department does not go to the middle school
on fort Lewis to give classes on STIs.
Community Health 31
3. How do you follow up on patients (to make sure they understand, are getting treatment, are
changing their ways, etc)?
The units have annual STI briefings but its up to the discretion of the commander. These
classes are given upon request and they are provided by the army public health nurses. The
Army is experiencing rapid deployments to Iraq and Afghanistan, STI briefings have not
been a priority for units. They are just way to busy in their training and preparations for
deployments for STI briefings.
4. What educational resources are available at Fort Lewis? How do you provide education or utilize
these resources for patients?
Education is the number one way to prevent sexual transmitted disease. The issue is
targeting the behavior of our soldiers; I see constant reckless and dangerous behavior from
our soldiers. The educational deficit in the young soldiers has contributed to the increased
rates of Chlamydia. When I was a Fort Gordon, the public health was responsible for the
schools and the SAC clinic. Here at fort Lewis our roles are limited.
5. How should STIs be dealt with differently (What would you like to see change, How would you
make a change at Fort Lewis that you think would be beneficial to soldiers)?
I think that the idea to put condoms and flyers in the examination room is a great idea. I also
think adding the educational teaching to the screening form will increase the quality of
education. Nurses need to be involved in the SAC clinic. Our roles are limited in working
with STI patients. We need to implement an RN in the STI clinic to provide the education
and holistic care.
I think your proposed interventions are great and terrific. The Flyers will raise awareness of
the STD clinic and assures the soldiers that their confidentiality is respected. I recommend
that you mention on the flyer that the chain of command will not be involved whatever the
outcomes are and that information is on a need to know bases.
Interview
LTC Baker- Chief of Preventive Medicine, Madigan Army Medical Center
1. Do you think that STIs are a problem at Fort Lewis?
Yes, STIs are a huge issue here at Fort Lewis, the statistics show it, and the infection rates are
rising every day. If you want specific rates for STDs go and see Mr. Johnson at the special adult
clinic.
2. What STIs are most commonly seen here?
Community Health 32
Mostly Chlamydia is seen the most here and Herpes has been a trend lately.
3. How do you follow up on patients (to make sure they understand, are getting treatment, are
changing their ways, etc)?
Contact screenings are done here at Fort Lewis to map out the chain of infection. This is an
important role for the army public health nurse. In addition some STI‘s must be reported to
the CDC and the department of health. During this process the PHN investigates the contact
history of the individual and conducts an epidemiological history.
4. What educational resources are available at Fort Lewis? How do you provide education or utilize
these resources for patients?
We have brochures, pamphlets and other resources available to our service members. There
is a clinic here dedicated to STIs called the special adult clinic. The SAC clinic is a walk in
self referred clinic open to soldiers and civilians. The hours of operation are 0730-1000 M-F
and there is a physician‘s assistant and LPN working there.
5. How should STIs be dealt with differently (What would you like to see change, How would you
make a change at Fort Lewis that you think would be beneficial to soldiers)?
I think the education process can be improved at the SAC clinic. They have an LPN (Mrs.
Penny) and a PA (Mr. Johnson) along with a secretary and a medic. I think the quality of
care offered at the SAC clinic can be improved if the staffing is increase. Additionally the
hours of operation can be increased to give soldiers more options. It could be
counterproductive for production of work if the hours of operation are only from 0730-1030.
I think there is a missed opportunity for behavior modification among Fort Lewis soldiers.
We need to do a better job of getting people screened before they are at risk. We need to do
a better job counseling our military on behavior modification.
Interview
Mr. Johnson- Physician Assistant at the Special Adult Clinic
Do you think that STIs are a problem at Fort Lewis?
Yes I do, we need look at our population to stop the spread of infection. Teen education—he
thinks education is a great thing, but is primarily the parents‘ job. Need for education-High
Schools need to reinforce some moral issues—having sex could be dangerous and risk to health.
STI are a problem everywhere, they are also a problem in the military. The increase in STIs may
be to the generation, young people today have very different life styles
What STIs are most commonly seen here?
Three most common STI seen on Ft. Lewis
Chlamydia
Herpes
Community Health 33
Genital Warts
How do you follow up on patients (to make sure they understand, are getting treatment, are
changing their ways, etc)?
Try to educate about the need for safe sex, condoms all the time, but that still is not 100 % safe.
There is a limited amount of information a person will retain on a visit.
What educational resources are available at Fort Lewis? How do you provide education or
utilize these resources for patients?
There are programs at unit level training available upon request. Also Soldiers are given a class
during basic training.
How should STIs be dealt with differently (What would you like to see change, How would you
make a change at Fort Lewis that you think would be beneficial to soldiers)?
Plan-make soldiers more aware of SAC to come for screenings—via hand outs, posters in Waller
Hall—―Had Sex?‖ (Got Milk?)
Contract tracing could significantly decrease the STI rates, epidemiological investigation These
are social issues related directly to public health